Contrast-enhanced ultrasonography to diagnose complicated acute cholecystitis

Abstract

Gangrenous cholecystitis and perforation are severe complications of acute cholecystitis, which have a challenging preoperative diagnosis. Early identification allows better surgical management. Contrast-enhanced computed tomography (ceCT) is the current diagnostic gold standard. Contrast-enhanced ultrasonography (CEUS) is a promising tool for the diagnosis of gallbladder perforation, but data from the literature concerning efficacy are sparse. The aim of the study was to evaluate CEUS findings in pathologically proven complicated cholecystitis (gangrenous, perforated gallbladder, pericholecystic abscess). A total of 8 patients submitted to preoperative CEUS, and with subsequent proven acute complicated cholecystitis at surgical inspection and pathological analysis, were retrospectively identified. The final diagnosis was gangrenous/phlegmonous cholecystitis (n. 2), phlegmonous/ulcerative changes plus pericholecystic abscess (n. 2), perforated plus pericholecystic abscess (n. 3), or perforated plus pericholecystic biliary collection (n. 1). Conventional US findings revealed irregularly thickened gallbladder walls in all 8 patients, with vaguely defined walls in 7 patients, four of whom also had striated wall thickening. CEUS revealed irregular enhancing gallbladder walls in all patients. A distinct wall defect was seen in six patients, confirmed as gangrenous/phlegmonous cholecystitis at pathology in all six, and in four as perforation at macroscopic surgical inspection. CEUS is a non-invasive easily repeatable technique that can be performed at the bedside, and is able to accurately diagnose complicated/perforated cholecystitis. Despite the limited sample size in the present case series, CEUS appears as a promising tool for the management of patients with the clinical possibility of having an acute complicated cholecystitis.

Evaluation of Contrast‐enhanced Ultrasonography as a Method for Detecting Gallbladder Necrosis or Rupture in Dogs

“…the gallbladder wall, which appears in advance to that of liver parenchyma during the arterial phase and remains enhanced during the portal phase . The results of the present study confirm that the real‐time visualization by CEUS of the whole enhanced gallbladder wall was very useful in assessing the presence of focal vascular defects characterized by complete lack of enhancement, as has been reported in human studies . At the same time, the presence of gallbladder wall edema was characterized by the double‐rim hyper‐enhancement of the wall.…”

“…Although subjective, the lack of contrast enhancement indicates that there is no viable tissue present. In this context, CEUS proved to be 100% accurate in detecting gallbladder wall necrosis/rupture in dogs, which is in good agreement with studies performed in humans with necrotizing cholecystitis and gallbladder rupture . However, with CEUS, the observed enhancement patterns reflect the underlying pathological process rather than a specific disease, as has been widely documented in studies performed in human patients with gallbladder diseases .…”

“…A diagnosis of gallbladder necrosis/rupture was suspected when the wall appeared discontinuous with one or more nonenhanced areas . Gallbladder wall edema was diagnosed when a double‐rim mark was present together with a thickened wall …”

“…Contrast‐enhanced ultrasonography (CEUS) utilizes gas‐filled microbubbles administered intravenously to obtain real‐time perfusion images of target organs and/or lesions . Recently, the use of CEUS has been extended to imaging of the gallbladder in humans for the diagnosis of several gallbladder pathologies, including gallbladder wall perforation secondary to acute necrotizing cholecystitis, with results comparable to those obtainable with computed tomography . However, CEUS cannot discriminate between necrotic areas and rupture of the gallbladder wall because both conditions image as nonperfused regions .…”

“…Recently, the use of CEUS has been extended to imaging of the gallbladder in humans for the diagnosis of several gallbladder pathologies, including gallbladder wall perforation secondary to acute necrotizing cholecystitis, with results comparable to those obtainable with computed tomography . However, CEUS cannot discriminate between necrotic areas and rupture of the gallbladder wall because both conditions image as nonperfused regions . To our knowledge, there have been no studies using CEUS in the diagnosis of gallbladder diseases in dogs.…”